Connor O’Sullivan

Age: 4years, 2 months old male

Full Case

Patient's Data

Patient’s name: Connor O’Sullivan

Age: : 4years, 2 months old male

Past Medical History

  • Born through normal vagina delivery.
  • Otitis media 9 months ago, treated with PO amoxicillin.

Drug history

  • No known drug allergy.
  • Not on any current medication.

Recent notes / Consultation

Missed routine appointment with Nurse for MMR vaccine (2nd dose) and 4-in-1 pre-school booster vaccine scheduled over 9 months ago- 2 text messages sent.
3 weeks ago–Seen by Kate Walsh (Nurse Access role):
MMR vaccine (2nd dose) administered. Advised to book another separate appointment for 4-in-1 pre-school booster.
Letter from Child Therapy unit–Did not attend paediatric physiotherapist appointment for in-toeing scheduled 2 weeks ago. Patient discharged back to GP –for GP to resend referral if still needed.

Mother- Siohban Hughes—booked appointment to discuss issues.

Patient's Story (Role Play)

Patient’s Story – Siobhan (Mother of Connor)
You are Siobhan, the mother of Connor (4-years, 2 months-old male). You’re calling today because the health visitor who saw Connor yesterday advised you to contact the GP.
Connor developed right ear pain two days ago. Yesterday, you noticed a yellowish discharge coming from that ear. He also has a fever.
You gave him Calpol, thinking it was just a viral infection, but the health visitor felt he may need antibiotics and recommended you speak to a doctor.
Connor is otherwise drinking, eating, and passing urine normally. He seems generally well in himself aside from the ear symptoms.
If asked about any other symptoms (e.g. rash, sore throat, vomiting, balance issues), say NO.
You are a single mother, currently at work. Connor is with your parents, but they can’t bring him to the surgery—they don’t drive, and your mum is also caring for your dad, who has dementia.
You also have an 8-year-old child who is in school and doing fine.
PBIND (Pregnancy, birth, immunisation nutrition, development) history:

Pregnancy & birth: Normal vaginal delivery, no complications.

Immunisations: Not fully up to date
Nutrition & development: Eating well, growing normally, developmentally on track
If the doctor asks why Connor is behind on his vaccinations, explain that you’re trying your best, but it’s sometimes difficult to arrange appointments due to your work schedule and the need to coordinate with your mum, who helps with childcare.
Connor’s father is not involved in their lives.

Ideas: You suspect it’s an ear infection.
Concerns: You’re worried because his symptoms haven’t improved, and the health visitor said he may need antibiotics.
Expectations: You’re hoping the GP can prescribe antibiotics.
Follow whatever advice the doctor gives.

 

Marking Scheme

History taking

  • Ask whether the pain is in one ear or both.
  • Ask if the pain gets worse when the ear is pulled (particularly the tragus), which may suggest otitis externa.
  • Ask about the onset and duration of the pain.
  • Ask if there has been any ear discharge.
  • Ask about any swelling or redness behind the ear (to rule out mastoiditis).
  • Ask if the child has had a fever.
  • Ask about any hearing loss or changes in hearing.
  • Ask about associated flu-like symptoms such as a runny nose, blocked nose, or sore throat.
  • Ask if the child has been swimming recently or had prolonged exposure to bath water, which can predispose to otitis externa.
  • Ask if the child has a history of recurrent ear infections.
  • Ask about red flag symptoms such as neck stiffness, unsteadiness, or headache (to rule out more serious complications).
  • Ask if the child is passing urine normally or, if in nappies, whether wet nappies are as expected.
  • Ask about the reason for missing the physiotherapy appointment and the vaccinations.
  • Ask if there are other children at home and whether they are well.
  • Ask if the caregiver is coping and managing to look after the children.
  • Ask about the mother’s Ideas, Concerns, and Expectations (ICE) regarding the child’s condition.
  • Give diagnosis of acute otitis media, a common childhood infection often following a viral upper respiratory tract infection.

Explanation To Patient

Explain to the mum as below:
Siobhan, thank you for calling in today — I understand how busy things must be for you, and I really appreciate you taking the time to discuss Connor’s symptoms. You’ve done the right thing by reaching out, especially after the health visitor’s advice.
From what you’ve described — ear pain, fever, and yellowish discharge from his right ear — it sounds very much like a middle ear infection, known as otitis media. It’s quite common in young children and often follows a cold or congestion. The fact that there’s now discharge suggests that the eardrum may have burst slightly, which can relieve the pressure and pain — that’s quite typical and usually heals on its own.
Given that it’s been over 48 hours and there’s discharge along with fever, I think it would be reasonable to start antibiotics. I can send a prescription for you to collect — you should start the course straight away. Make sure he continues to drink plenty of fluids and you can also give paracetamol or ibuprofen to help with fever and pain.
If Connor’s symptoms don’t improve within the next couple of days, or if they get worse — especially if he develops swelling or redness behind the ear, becomes unusually drowsy, or is not passing urine as usual — please let us know immediately or call 111 or 999, depending on the situation.
I’d also like to see Connor in person, if possible, just to check his ears and general health — but I completely understand that you’re at work, and your parents can’t bring him in today. We can arrange a follow-up in 2–3 days, either by phone or face-to-face, depending on what works best for you.
I also noticed from our records that he missed his 4-in-1 preschool booster, and there was a missed physiotherapy appointment for his in-toeing. These things are important, and I understand that juggling work and caring for two children on your own is challenging. But to make sure Connor’s health needs are fully met, it’s really important that we try not to miss appointments where possible. If things ever feel overwhelming, please don’t hesitate to speak to us, we can offer support or refer you to services that help parents manage in difficult situations.
Let’s get a new referral to the physiotherapy team arranged for you, and I’ll also ask our reception team to help you book Connor’s missed vaccinations — we want to make sure he’s fully protected.
Finally, I’ll document everything we’ve discussed and arrange that prescription now. Would you prefer to pick it up from the pharmacy directly or from the surgery?

Management

Management

  • Offer a face-to-face appointment to examine Connor’s ears, check his temperature, and assess his overall condition.
  • If the mother cannot bring Connor in due to her current situation, provide appropriate advice over the phone and arrange a follow-up option that suits her needs.
  • Since Connor has had ear pain and now discharge for more than 48 hours, and is showing signs of infection, an immediate antibiotic prescription is appropriate.
    Alternatively, if symptoms are not worsening but haven’t improved, offer a delayed prescription with advice to start antibiotics if things don’t improve within 24 hours or worsen at any point.
  • Advise regular fluid intake and the use of paracetamol or ibuprofen to manage fever and pain.
  • Let the mother know that you will re-book the physiotherapy referral for his in-toeing and help her arrange his missed vaccinations.
  • Acknowledge her situation as a busy single parent, and gently explain the importance of attending health appointments for Connor’s wellbeing. Emphasise that if she cannot attend, it’s always best to call and rearrange as soon as possible.
  • Reassure her that you’re here to support her, but explain that if further appointments are missed, the practice may need to consider a safeguarding referral, simply to ensure Connor’s health needs are being properly met.
  • Encourage her to let the practice know if she feels she’s struggling, and that support is available either through the GP team or local family support and social care services.
  • Safety netting advice: advise her to seek urgent help if Connor develops worsening symptoms such as: Swelling or redness behind the ear, Neck stiffness or severe headache, becoming unusually sleepy or drowsy, not passing urine or wetting nappies
  • Arrange a follow-up review in 2–3 days to check on Connor’s progress.

Lesson from this station

Learning Point from This Station
This station highlights the importance of clinical flexibility and empathy when managing unwell children in a remote consultation — especially when practical barriers (like childcare, transport, or work pressures) prevent in-person attendance.
It reinforces the need to:

  • Recognise otitis media with perforation when ear discharge follows pain and fever.
  • Safely prescribe antibiotics when symptoms have lasted more than 48 hours or are worsening.
  • Provide clear safety-netting for signs of complications like mastoiditis or systemic illness.

It also underlines the GP’s role in promoting continuity of care, especially for children who have missed vaccinations or therapy appointments, and the importance of gentle but firm communication when supporting single parents — balancing empathy with a reminder of the child’s ongoing health needs.
If missed appointments persist despite support, safeguarding may need to be considered to ensure the child’s wellbeing is not compromised.

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